Journal of Medical Ultrasonics

https://doi.org/10.1007/s10396-020-01030-w

SPECIAL FEATURE: REVIEW ARTICLE

Everything you need to know about ultrasound for diagnosis of gallbladder diseases

Role of endoscopic ultrasound for gallbladder disease

Kazunari Tanaka1 · Akio Katanuma1 · Tsuyoshi Hayashi1 · Toshifumi Kin1 · Kuniyuki Takahashi1

Received: 10 February 2020 / Accepted: 18 May 2020

© The Author(s) 2020

Abstract
Endoscopic ultrasonography (EUS) has excellent spatial resolution and allows more detailed examination than abdominal
ultrasonography (US) in terms of qualitative diagnosis of tumors and evaluation of tumor invasion depth. To understand the
role of EUS in gallbladder disease, we need to understand the normal gallbladder wall structure and how to visualize it on
EUS. In addition, gallbladder lesions can be classified into two broad categories: protuberant and wall-thickening lesions.
Here, the features on EUS were outlined. We also outlined the current status of EUS-FNA for gallbladder lesions as there
have been scattered reports of EUS-FNA in recent years.

Keywords EUS · EUS-FNA · Gallbladder polyp · Gallbladder carcinoma

Introduction Herein, we describe the current applications of EUS-FNA

Ultrasonography (US) is widely performed as a screening
test for gallbladder lesions as it is less invasive and can be
done easily. Computed tomography (CT) or magnetic reso-
nance imaging (MRI) is often used for further evaluation
when clinical questions persist after US has been performed.
CT is suboptimal for spatial resolution and hence limited
in its ability to provide differential diagnosis of gallbladder
lesions. However, it is useful for diagnosis of the presence
of certain large gallbladder lesions and their progression. In
cases where malignancy is suspected based on other tests,
a qualitative diagnosis by MRI is useful. It is also possible
to understand the overall picture of the disease by magnetic
resonance cholangiopancreatography. EUS has a high spatial
resolution and allows for a more detailed examination of the
gallbladder because it can approach and examine the organ
at a closer range than US. This makes it possible to make
a qualitative diagnosis of lesions and evaluate tumor inva-
sion depth with EUS. There have also been recent studies
on EUS fine-needle aspiration (FNA) in gallbladder disease.
Thus, EUS-FNA may potentially augment difficulties in the
pathological examination of gallbladder lesions.
* Kazunari Tanaka
kazunari0511@gmail.com
1
Center for Gastroenterology, Teine Keijinkai Hospital,
1‑40‑1‑12 Maeda, Teine‑ku, Sapporo 006‑8555, Japan
for gallbladder lesions.
1. Normal anatomy of the gallbladder wall
In US, the gallbladder wall is visualized as two layers, a
hypoechoic inner layer and a hyperechoic outer layer, which
correspond to the mucosa through the shallow and deep sub-
serosal layers, respectively [1] (Fig. 1). Normally, the gall-
bladder wall is at most 3 mm thick with a smooth luminal
surface. A gallbladder wall measuring ≥ 4 mm is considered
to be thickened.
2. Methods for visualization of gallbladder lesions
by EUS
There are two types of EUS scopes, radial scanning and
convex array. These devices provide different images and
are therefore used in various visualization methods. Kaneko
et al. [2] performed a prospective comparative study on the
differences in visualization between these two devices in the
examination of the pancreaticobiliary region.
With regard to gallbladder long-axis visualizing capabil-
ity, convex array EUS was inferior to radial scanning EUS.
However, there was no significant difference in the lesion
imaging and new lesion imaging between the two groups.
Hence, in settings where both devices are available for use,
the features of each device should be clearly understood, and

13
Vol.:(0123456789)

Fig. 1  Normal gallbladder. The gallbladder wall is divided into an
inner low echoic layer and an outer high echoic layer
proper use should be implemented according to the patient’s
medical condition.
To minimize oversight in testing, confirmation using
different modalities such as magnetic resonance cholangio-
pancreatography is important before EUS. As the gallblad-
der structure and position vary from patient to patient, the
gallbladder curvature and the positions of lesions should
be verified in advance, preventing oversight during EUS.
The position of the gallbladder fundus, in particular, var-
ies largely between individuals, and caution is necessary as
failure to ascertain the overall gallbladder structure before
performing the examination may result in lesion oversight
and inability to obtain accurate observations.
The key points for gallbladder examinations for each type
of EUS are presented below.
Fig. 2  Radial scan type (short-
scope position). a Short-scope
position. b EUS image of the
gallbladder in the short-scope a b
position
13
Journal of Medical Ultrasonics
i) Radial scan type
For a gastric scan, after observing the pancreas, advance the
scope into the descending duodenum and stretch the scope
into the short scope position. Inflate the balloon slightly,
identify the bile ducts, withdraw while rotating counter-
clockwise, and identify the cystic duct junction. Inflate the
balloon further, withdraw the scope, and examine from the
cystic duct to the neck of the gallbladder (Fig. 2a). Depend-
ing on the patient, it may be possible to examine the whole
gallbladder, including the fundus (Fig. 2b). In cases where
the whole gallbladder cannot be examined in the short scope
position, in the duodenal bulb, press the scope tip against the
superior duodenal flexure, tilt the scope upward, and lightly
advance it assuming a long scope position (Fig. 3a). Clock-
wise rotation causes the scope to advance in the direction
of the descending duodenum (Fig. 3b). Visualize the cystic
duct junction, and successively examine the cystic duct and
the neck, body, and fundus of the gallbladder (Fig. 3c). Dur-
ing this procedure, the short scope position and gallbladder
direction are opposite. In transgastric scanning, observation
may be possible by either withdrawing the scope with the
balloon inflated from the short scope position or pressing the
scope against the pyloric ring with the balloon inflated and
assuming the long scope position.
ii) Convex array
When examining the gallbladder by transgastric scanning,
it is easier to identify the bile ducts using the portal vein as
the starting point. By following the intrahepatic portal vein
of the left lobe of the liver and identifying the hilar portal
vein, the hilar hepatic ducts can be visualized in the deep
part of the portal vein (Fig. 4a).
Journal of Medical Ultrasonics

Fig. 3  Radial scan type (long-

scope position). a Long-scope
position in the duodenum bulb. a b c
b Clockwise rotation causes
the scope to advance in the
direction of the descending
duodenum

Accordingly, visualization of the cystic duct junction is
occasionally possible by continuing to advance the scope,
and visualization from the cystic duct to the gallbladder
neck is occasionally possible by rotating the scope (Fig. 4b).
However, as the direction of rotation at this point varies with
each patient, visualization should be performed while care-
fully following the cystic duct (Fig. 4c). Note that examina-
tion of the entire gallbladder from within the stomach is not
always possible.
In duodenal bulb scanning, the hilar hepatic ducts are
identified by visualizing the portal vein and tilting the scope
downward while withdrawing it in counterclockwise rotation
(Fig. 5a). The cystic duct junction can be recognized through
this process (Fig. 5b). By rotating the scope while following
the cystic duct, it is possible to visualize the whole gallblad-
der from the neck to the fundus (Fig. 5c). As the direction
of rotation at this point also varies from patient to patient,
it is important to make a thorough observation including
the gallbladder fundus by visualizing successively from the
cystic duct toward the gallbladder neck.
iii) Contrast‑enhanced harmonic EUS
Although contrast-enhanced harmonic EUS for gallbladder
disease is not covered by health insurance, Choi et al. [3]
have reported that the presence of irregular intratumoral
vessels and a perfusion defect on contrast EUS can diag-
nose gallbladder cancer in gallbladder polyps measuring at
least 10 mm with a sensitivity and specificity of 93.5 and
93.2%, respectively (Fig. 6). Imazu et al. [4] also reported
that inhomogeneously enhanced patterns were observed in
contrast EUS. However, further accumulation of knowledge
is desired as there has been apparently no large-scale study

Fig. 4  Convex array (transgas-

tric scanning). a EUS image of
the cystic duct junction. b EUS
image of the gallbladder neck a
and body. Gn: neck of gallblad-
der, Gb: body of gallbladder

13
 Journal of Medical Ultrasonics

Fig. 5  Convex arrayed (duo-

denal bulb scanning). a EUS b
image of the cystic duct and
gallbladder neck and body. a
b Fundus of gallbladder. Gf:
fundus of gallbladder

Fig. 6  Contrast EUS for

gallbladder carcinoma. a
Conventional EUS demonstrates
a hypoechoic mass in the gall-
bladder. b Contrast-enhanced
harmonic EUS indicates that
the area has perfusion defects
(arrow)

on contrast-enhanced harmonic EUS in gallbladder diseases
to date.
3. Differential diagnosis of gallbladder lesions
Gallbladder lesions are broadly divided into protuber-
ant and wall-thickening lesions. Protuberant lesion is an
inclusive category encompassing a variety of diseases,
both epithelial and non-epithelial, as well as benign and
malignant diseases. It is a generic term for lesions that
have the specific morphological feature of forming a pro-
tuberance localized to the luminal side of the gallbladder
[5]. In differentiating protuberant gallbladder lesions, the
classification of benign protuberant lesions by Christensen
et al. is used [6]. However, from a clinical perspective, the
significance of treating lesions collectively as gallbladder
polyps before a definitive diagnosis lies in the early detec-
tion of malignant disease from these lesions. Therefore,
protuberant gallbladder lesions are first divided into neo-
plastic and non-neoplastic lesions. Differential diagnoses
such as adenomas or carcinomas for neoplastic lesions and
cholesterol polyps, hyperplastic polyps, and gallbladder
adenomyomatosis for non-neoplastic lesions are based on
size, pedunculation, morphology, surface characteristics,
and internal echo. On the other hand, wall-thickening
lesions denote lesions in which the gallbladder wall is dif-
fusely thickened. Differential diagnosis is made with ref-
erence to the extent of wall thickening, surface structure,
and presence or absence of Rokitansky–Aschoff sinuses
(RAS).

13
Journal of Medical Ultrasonics

Ultrasonographic features of gallbladder protuberant
lesions and gallbladder wall-thickening lesions are summa-
rized in Tables. 1 and 2, respectively.
4. Protuberant lesions
i) Non‑neoplastic lesions (gallbladder polyps)
Gallbladder polyps are small, localized, raised lesions
observed on the mucosal surface of the gallbladder. Histo-
pathologically diverse diseases are included, whether benign
or malignant, neoplastic or non-neoplastic, and epithelial
or non-epithelial. In daily clinical practice, benign lesions
measuring < 2 cm are usually detected [7]. Most gallbladder
polyps are asymptomatic and discovered incidentally during
medical or comprehensive health examinations. The preva-
lence rate is reported to be within 4.2–9.5% in East Asia
[8–11] and 3–7% in Western countries [12].
The main types of gallbladder polyp are as follows:
A. Cholesterol polyps: These are the most common
gallbladder polyps and comprise 62.8% of all gallbladder
polyps. Although multiple polyps measuring ≤ 10 mm are
highly likely to be cholesterol polyps, [5] caution is nec-
essary as 5% of polyps are cancerous even if they meas-
ure ≤ 10 mm [13]. The characteristic findings on EUS are a
deeply notched granular surface and morular morphology.
The internal echo is rough or granular, and highly echogenic
punctiform foci reflecting cholesterolosis are visible [14]
(Fig. 7). Peduncles are thin and frequently unobserved even
on EUS.
When polyps reach ≥ 10 mm, epithelial hyperplas-
tic changes are reflected as lobulation, and internal echo
decreases, making differentiation from adenoma and early
gallbladder cancer difficult in some cases and necessitating
caution (Fig. 8).
B. Hyperplastic polyps: Hyperplastic polyps are classified
as proper epithelial or metaplastic epithelial polyps, and they
frequently multiply. The proper epithelial type occurs sin-
gly, measures ≥ 10 mm, is papillated to lobulated, and shows
relative internal uniformity. If accompanied by cholesterolo-
sis, internal punctiform echogenic foci are observed, which
complicates differentiation from cholesterol polyps (Fig. 9).
C. Inflammatory, fibrous, and granulomatous polyps:
Whether to treat inflammatory, fibrous, and granulomatous
polyps as distinct or similar remains controversial. Inflam-
matory polyps are relatively rare, comprising 1.4–12% of
gallbladder polyps [15–18]. These polyps, which result from
hyperplasia of edematous loose connective tissues, are inter-
nally hypoechoic and occasionally accompanied by inflam-
matory thickening of the gallbladder wall.
The characteristic EUS findings are internal anechoic
spots with hyperechoic polyp surface borders. These find-
ings appear to occur because of the difference in the acoustic
features between the single surface layer of the columnar

Table 1  Ultrasonographic Form Surface Internal echo

features of gallbladder
protuberant lesions
Cholesterol polyp ・Morular or oval ・Granular ・Rough or granular
・Highly echogenic punctiform foci
Hyperplastic polyp ・Papillated or lobulated ・Smooth ・Low echogenicity
・Uniform low echogenicity
Inflammatory polyp ・Ovla or lobulated ・Smooth ・Anechoic spots
Fibrous polyp ・Hyperechoic polyp ・Uniform low echogenicity
Granulomatous polyp surface border
Adenomyomatosis ・Sessile or oval ・Smooth ・Anechoic spots
・Comet tail artifact
・Uniform low echogenicity
Adenoma ・Oval ・Smooth or nodular ・Solid echogenicity
・Multiple microcystic spaces
Gallbladder carcinoma ・Oval or irregular ・Smooth or irregular ・Uniform internal echo
・Dense solid echo

Table 2.  Ultrasonographic Surface Internal echo

feature of gallbladder wall
thickened lesions
Adenomyomatosis ・Smooth or irregular ・Cystic anechoic spots
・Comet tail artifacts
Xanthogranulomatous cholecystitis ・Smooth ・Mixed hyperechoic and
hypoechoic echotexture
Anomalous pancreaticobiliary junction ・Smooth ・Uniform low echogenicity
Gallbladder carcinoma ・Irregular or papillated ・Uneven hypoechogenicity

13
 Journal of Medical Ultrasonics

Fig. 7  Cholesterol polyp. a This

polyp has a granular surface
and morular morphology.
The internal echo is rough or
granular. b Polypoid lesion with
non-neoplastic epithelium and
abundant stroma

Fig. 8  Cholesterol polyp resem-

bling early gallbladder carci-
noma. a EUS image of a solid
internal echogenicity polyp
without echogenic punctiform
foci. b (1, 2) Photomicrograph
demonstrating an aggregation of
foamy cells under the epithe-
lium

epithelium and the edematous stroma [19] (Fig. 10). Fibrous
polyps are made up of connective tissue composed of fibro-
blasts, fibrocytes, and collagen fibers, and imaging findings
resemble those of inflammatory polyps (Fig. 11). Granu-
lomatous polyps, which are formed from inflammatory
granulation tissue, lack a surface epithelium and have a high
rate of comorbidity with acute cholecystitis and gallstones.
ii) Neoplastic lesions
A. Adenomas: Adenomas are classified as tubular or pap-
illary. Tubular adenomas, of which pyloric adenomas are
common, are pedunculated to subpedunculated and oval.
The features on EUS are a relatively smooth or nodular
surface, solid internal echogenicity, and the presence of
enlarged neoplastic glandular ducts observed as multiple
microcystic spaces [20] (Fig. 12). Papillary adenomas are
predominantly of the proper epithelial type with a low solid
echo and must be differentiated from hyperplastic polyps.
Differentiation between adenomas and adenocarcinomas
based on imaging is considered difficult.
B. Gallbladder carcinoma (protuberant type): Gall-
bladder carcinoma is considered in cases of diffuse or
localized irregular thickening of the gallbladder wall in
which an irregular mucous membrane surface and a loss
of uniformity in the inner hypoechoic layer are observed.
Ultrasound imaging findings are classified as protuberant
(peduncular/sessile), wall thickening, or both types. Of
the protuberant type, peduncular lesions (type Ip) often

13
Journal of Medical Ultrasonics

Fig. 9  Gallbladder hyperplastic

polyp. a EUS image of a pedun-
culated, lobulated, solid internal
echogenicity polyp. b (1, 2) The
polyp consists of duct glands
similar to the pyloric gland

Fig. 10  Gallbladder inflamma-

tory polyp. a EUS image show-
ing a pedunculated, smooth
surface polyp with an anechoic
area. b (1, 2) The stroma con-
sists of edematous and coarse
fibrous connective tissue. The
surface iconsists of simple
columnar epithelium

show morphological resemblance to adenomas (Fig. 13), 5. Wall‑thickening lesions

uniform internal echo, and dense solid echo. Adenocar-
cinomas are common among type Ip, whereas sessile
lesions (types Is and IIa) are frequently accompanied by
associated neighboring IIa and flat lesions. Because the
layered structure can be examined in detail by EUS, type
Is lesions with a deep hypoechoic area or thinning of the
hyperechoic outer layer (Fig. 14) can be diagnosed as gall-
bladder carcinoma with SS depth of invasion. However,
in cases where the hyperechoic outer layer is retained, the
depth of invasion may extend to the mucous membrane,
muscularis, or shallow SS layer, depending on the case,
and differentiation is difficult even by EUS.
i) Gallbladder adenomyomatosis
Histopathologically, gallbladder adenomyomatosis is a
disease that causes RAS and thickening of the gallbladder
wall owing to smooth muscle and fibrous tissue hyperplasia.
Based on the location and morphology of the wall lesions,
gallbladder adenomyomatosis is classified as fundal (with a
focal lesion involving the gallbladder’s fundal region), seg-
mental (with thickening of the gallbladder neck or body), or
diffuse (with RAS hyperplasia and thickening that involve
the whole gallbladder wall) (Fig. 15).
In gallbladder adenomyomatosis, the thickened wall has a
smooth surface but occasionally exhibits surface irregularity,
reflecting hyperplastic changes. A key point in its diagnosis

13
 Journal of Medical Ultrasonics

Fig. 11  Gallbladder fibrous

polyp. a EUS image show-
ing a pedunculated, smooth
surface, uniformal echogenicity
hypoechoic polyp. b (1, 2) The
stroma consists of edematous
and coarse fibrous connective
tissue. The surface consists of
simple columnar epithelium

Fig. 12  Gallbladder adenoma.

a (1, 2) EUS image showing a
relatively smooth surface, solid
internal echogenicity polyp with
multiple microcystic spaces. b
Photomicrograph imaging of
the gallbladder adenoma

is to confirm the presence of cystic anechoic spots reflecting
RAS inside the thickened wall. Comet tail artifacts are also
occasionally observed owing to multipath reflection from
RAS or intramural calculi.
ii) Xanthogranulomatous cholecystitis
Xanthogranulomatous cholecystitis is a unique form of
cholecystitis in which the gallbladder wall thickening
primarily involves the SS layer and is accompanied by
irregular thickening of the gallbladder wall and fibrosis.
As the inflammation occasionally affects surrounding
organs such as the liver and transverse colon, differentia-
tion from gallbladder carcinoma is frequently problematic.
The disease may result from impaction of stones in the
neck of the gallbladder or biliary leakage into the gallblad-
der wall owing to RAS rupture or mucosal ulceration. In
cases without lithiasis, gallbladder carcinoma may be a
possible cause. Differentiation between benign and malig-
nant types based on EUS alone is frequently difficult.

13
Journal of Medical Ultrasonics

Fig. 13  Early gallbladder

carcinoma. a (1, 2) EUS image:
A homogenously hypoechoic
protruding lesion with a
granular surface is seen. The
outer layer of the gallbladder is
well preserved (arrow, retained
hyperechoic outer layer; arrow-
head, normal hyperechoic outer
layer). b Photomicrograph: A
pedunculated polypoid lesion
was diagnosed as well-differen-
tiated adenocarcinoma. It was
invading into but not through
the muscularis layer

Fig. 14  Advanced gallbladder

carcinoma. a EUS imaging of a
sessile elevated lesion with thin-
ning of the hyperechoic outer
layer (arrow, thinning of the
hyperechoic outer layer; arrow-
head, normal hyperechoic outer
layer). b (1, 2) Photomicro-
graph: Gallbladder carcinoma
with SS depth invasion

Fig. 15  Gallbladder adenomy-

omatosis. a Fundal type. b Dif- b
fuse type. c Segmental type
a

13
 Journal of Medical Ultrasonics

iii) Hyperplasia of the gallbladder mucous membrane
accompanying anomalous pancreaticobiliary junction
As an anomalous pancreaticobiliary junction leads to
reflux of pancreatic juice into the biliary tract, hyperplas-
tic changes arise in the gallbladder mucous membrane
(Fig. 16). Hyperplasia of the gallbladder mucous mem-
brane is recognized in 38–63% of patients with an anoma-
lous pancreaticobiliary junction, with an even higher rate
of 90–100% particularly in patients without bile duct dila-
tation [21, 22].
In hyperplasia of the gallbladder mucous membrane,
epithelial height is increased, cellular proliferative activ-
ity is accelerated, and a mechanism from hyperplasia to
dysplasia and carcinoma is speculated.
iv) Gallbladder carcinoma (wall‑thickening type)
In the wall-thickening type, differentiation from gallblad-
der adenomyomatosis and chronic cholecystitis is problem-
atic, but in gallbladder carcinoma, the mucous membrane is
irregular or papillated, thickened areas do not have uniform
thickness, and the layered structure is ill-defined. Further-
more, microcysts and comet tail artifacts reflecting RAS are
usually not observed (Fig. 17).
6. EUS‑FNA for gallbladder lesions
Bile duct biopsy is the first choice procedure in the patholog-
ical diagnosis of gallbladder lesions in which a biliary stric-
ture is present. However, when a biliary stricture is absent,
it is often necessary to rely on cytological examination of

Fig. 16  Hyperplasia of the

gallbladder mucous membrane
accompanying anomalous pan-
creaticobiliary junction. a EUS
image of the thickened inner
hypoechoic layer of the gall-
bladder. b Hyperplastic changes
in the gallbladder mucous
membrane. c ERCP image of
anomalous pancreaticobiliary
junction

Fig. 17  Gallbladder carcinoma

(wall-thickening type). a (1,
2) EUS image of irregular
gallbladder wall thickening
from the gallbladder body to
the fundus (arrow). b (1, 2)
Photomicrograph: Gallblad-
der carcinoma with SS depth
invasion

13
Journal of Medical Ultrasonics
Fig. 18  EUS-FNA for a
gallbladder lesions. a CT scan
shows a gallbladder lesion in
the gallbladder neck (arrow).
b EUS-guided FNA for a gall-
bladder mass lesion
bile collected from the gallbladder through the cystic duct,
which makes diagnosis difficult. Cytological examination
using endoscopic naso-gallbladder drainage does not always
have a high success rate, requires a highly proficient practi-
tioner, and presents problematic points such as perforation
of the cystic duct when using a guidewire [23–25].
Although EUS-FNA is highly useful and widely used for
pancreatic carcinoma and gastrointestinal lesions, the deci-
sion to use EUS-FNA for biliary tract lesions, particularly
gallbladder carcinoma, should be made with care because of
risks such as biliary fistula and dissemination to membranes.
Regional lymphadenopathy is often noted in unresectable
advanced gallbladder carcinoma [26]. Considering the risks
such as invasive biliary fistula, which may affect neighbor-
ing organs including the liver, and peritoneal dissemination,
aspiration from regional lymph nodes is preferable. Hijioka
et al. have reported that FNA can be performed in gallblad-
der lesions without compromising diagnostic performance
or safety [26]. Moreover, the diagnostic performance of
EUS-FNA in gallbladder lesions is high, with a sensitivity,
specificity, and diagnostic accuracy of 80–100%, 100%, and
83–100%, respectively [26–31].
When directly puncturing the gallbladder wall, despite
the care taken to gain stroke distance by tangentially punc-
turing the gallbladder wall (Fig. 18), the wall may move
if the gallbladder lumen remains and puncturing is often
difficult. In cases where lesions have invaded the liver, it is
recommended to puncture either the liver parenchyma as the
invasion site or the gallbladder wall that is in contact with
the liver parenchyma.
Conclusion
EUS is an important testing method that plays several sig-
nificant roles such as detection of gallbladder lesions, dif-
ferentiation between benign and malignant types, and eval-
uation of malignancy progression level. In the future, the
importance of EUS in this field is expected to grow further
with the use and establishment of EUS-FNA for gallbladder
lesions.
Acknowledgements We thank Dr. Edward Barroga (https​://orcid​
.org/0000-0002-8920-2607), Medical Editor and Professor of Aca-
demic Writing at St. Luke’s International University, for editing the
manuscript.
Compliance with ethical standards
Conflict of interest The authors declare that there are no conflicts of
interest.
Ethical approval All procedures followed were in accordance with the
ethical standards of the responsible committee on human experimenta-
tion (institutional and national) and with the Helsinki Declaration of
1964 and later versions.
Informed consent Informed consent was obtained from all patients for
being included in the study.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
References
1. Fujita N, Noda Y, Kobayashi G, et al. Analysis of the layer struc-
ture of the gallbladder wall delineated by endoscopic ultrasound
using the pinning method. Dig Endosc. 1995;7:353–6.
2. Kaneko M, Katanuma A, Maguchi H. Prospective, randomized,
comparative study of delineation capability of radial scanning and
curved linear array endoscopic ultrasound for the pancreaticobil-
iary region. Endosc Int Open. 2014;2:E160–E170170.
13

3. Choi JH, Seo DW, Choi JH, et al. Utility of contrast-enhanced
harmonic EUS in the diagnosis of malignant gallbladder polyps.
Gastrointest Endosc. 2013;78:484–93.
4. Imazu H, Mori N, Tajiri H, et al. Contrast-enhanced harmonic
endoscopic ultrasonography in the differential diagnosis of gall-
bladder wall thickening. Dig Dis Sci. 2014;59:1909–16.
5. Karaosmmanoglu AD, Blake M. Hamartomatous polyp of the
gallbladder with an associated choledochal cyst. J Ultrasound
Med. 2010;29:1663–6.
6. Christensen AH, Ishak KG. Benign tumors and pseudotu-
mors of the gallbladder. Report of 180 cases. Arch Pathol.
1970;90:423–32.
7. Park EJ, Lee HS, Lee SH, et al. Association between metabolic
syndrome and gallbladder polyps in healthy Korean adults. J
Korean Med Sci. 2013;28:876–80.
8. Chen CY, Lu CL, Chang FY, et al. Risk factors for gallblad-
der polyps in the Chinese population. Am J Gastroenterol.
1997;92:2066–8.
9. Xu Q, Tao LY, Wu Q, et al. Prevalence of and risk factors for bil-
iary stones and gallbladder polyps in a large Chinese population.
HPB. 2012;14:373–81.
10. Inui K, Yoshino J, Miyoshi H. Diagnosis of gallbladder tumors.
Intern Med. 2011;50:1133–6.
11. Lin WR, Lin DY, Tai DI, et al. Prevalence of and risk factors for
gall bladder polyps detected by ultrasonography among healthy
Chinese: analysis of 34669 cases. J Gastroenterol Hepatol.
2008;23:965–9.
12. Ahrendt SA, Pitt HA. Sabiston textbook of surgery. 17th ed. Phila-
delphia: Elsevier Saunders; 2004. p. 1597–1641.
13. Okada K, Kijima H, Imaizumi T, et al. Wall-invasion pattern cor-
relates with survival of patients with gallbladder adenocarcinoma.
Anticancer Res. 2009;29:685–91.
14. Azuma T, Yoshikawa T, Araida T, et al. Differential diagnosis of
polypoid lesions of the gallbladder by endoscopic ultrasonogra-
phy. Am J Surg. 2001;81:65–70.
15. Kubota K, Bandai Y, Makuuchi M, et al. How should polypoid
lesions of the gallbladder be treated in the era of laparoscopic
cholecystectomy? Surgery. 1995;117:481–7.
16. Terzi C, Sökmen S, Ugurlu M, et al. Polypoid lesions of the gall-
bladder: report of 100 cases with special reference to operative
indications. Surgery. 2000;127:622–7.
17. Sadamoto Y, Oda S, Nawata H, et al. A useful approach to the
differential diagnosis of small polypoid lesions of the gallbladder,
utilizing an endoscopic ultrasound scoring system. Endoscopy.
2002;34:959–65.
18. Lee KF, Wong J, Li JC, Lai PB. Polypoid lesions of the gallblad-
der. Am J Surg. 2004;188:186–90.
19. Kyokane T, Akita Y, Sato T, et al. A case of inflammatory
polyp of the gallbladder which was difficult to differentiate from
13
Journal of Medical Ultrasonics
cancer (in Japanese with English abstract). Jpn J Gastroenterol.
1994;91:1062–6.
20. Akatsu T, Aiura K, Shimazu M, et al. Can endoscopic ultrasonog-
raphy differentiate nonneoplastic from neoplastic gallbladder pol-
yps? Dig Dis Sci. 2006;51:416–21.
21. Hanada K, Itoh M, Hujii K, et al. Pathology and cellular kinetics
of gallbladder with an anomalous junction of pancreaticobiliary
duct. Am J Gastroenterol. 1996;91:1007–111.
22. Tsuchida A, Itoi T, Endo M, et al. Pathological features and surgi-
cal outcome of pancreaticobiliary maljunction without dilatation
of the extrahepatic bile duct. Oncol Rep. 2004;11:269–76.
23. Itoi T, Sofuni A, Itokawa F, et al. Endoscopic transpapillary
gallbladder drainage in patients with acute cholecystitis in
whom percutaneous transhepatic approach is contraindicated
or anatomically impossible (with video). Gastrointest Endosc.
2008;68:455–60.
24. Toyooka N, Takeda T, Amano H, et al. Endoscopic naso-gall-
bladder drainage in the treatment of acute cholecystitis: alleviates
inflammation and fixes operator’s aim during early laparoscopic
cholecystotomy. J Hepatobiliary Pancreat Surg. 2006;13:80–5.
25. Mutigeni M, Iacopini F, Perri V, et al. Endoscopic gallbladder
drainage for acute cholecystitis: technical and clinical results.
Endoscopy. 2009;41:539–46.
26. Hijioka S, Hara K, Mizuno N, et al. Diagnostic yield of endo-
scopic retrograde cholangiography and of EUS-guided fine needle
aspiration sampling in gallbladder carcinomas. J Hepatobiliary
Pancreat Sci. 2012;19:650–5.
27. Jacobson B, Pitman M, Brugge W. EUS-guided FNA for the diag-
nosis of gallbladder masses. Gastrointest Endosc. 2003;57:251–4.
28. Varadarajulu S, Eloubeidi M. Endoscopic ultrasound-guided fine-
needle aspiration in the evaluation of gallbladder masses. Endos-
copy. 2005;37:751–4.
29. Meara R, Jhala D, Eloubeidi M, et al. Endoscopic ultrasound-
guided FNA biopsy of bile duct and gallbladder: analysis of 53
cases. Cytopathology. 2006;17:42–9.
30. Hijioka S, Mekky MA, Bhatia V, et al. Can EUS-guided FNA
distinguish between gallbladder cancer and xanthogranulomatous
cholecystitis? Gastrointest Endosc. 2010;72:622–7.
31. Ogura T, Kurisu Y, Masuda D, et al. Can endoscopic ultrasound-
guided fine needle aspiration offer clinical benefit for thick-walled
gallbladders? Dig Dis Sci. 2014;59:1917–24.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.